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Health Inspection

Pennsburg Manor

March 26, 2026 · Pennsburg, PA · 530 Macoby Street
Citations 2
CMS Rating 4/5
Beds 120
Provider ID 395555
Healthcare Facility
Pennsburg Manor
Pennsburg, PA  ·  View full profile →
Inspection Summary

PENNSBURG MANOR in PENNSBURG, PA — inspection on March 26, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0690
Quality of Life and Care Deficiencies

Review of nursing documentation revealed that for the last 30 days, the resident was noted to be incontinent of urine greater then 50 times throughout the month.

There was no documented evidence that staff had completed a nursing assessment to determine the type of incontinence, voiding patterns, and any pertinent diagnoses that may affect bladder continence. In addition, there was no documented evidence that the facility developed a care plan with interventions to provide treatment and services to attempt to restore bladder continence. In an interview on March 26, 2026, at 9:35 a.m., the Director of Nursing confirmed that the resident had not been assessed for continence management and a care plan was not developed with interventions to attempt to restore as much bladder function as possible per facility policy. CFR 483.25(e)(2) IncontinencePreviously cited 5/6/25 28 Pa.

Code 211.12(d)(1)(5) Nursing services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

395555 03/26/2026

Pennsburg Manor 530 MacOby Street Pennsburg, PA 18073

Observation on March 24, 2026, at 12:40 p.m., revealed that a nurse aide (NA 1) collected a soiled gown and bed linens from Resident 2 without the use of a gown or gloves, carried them unbagged to the soiled closet, then obtained a mechanical lift for the resident.

Staff did not wash or sanitize her hands before obtaining the lift for the resident. NA 1 entered Resident 2's room to transfer Resident 2 with a registered nurse (RN 1) and the mechanical device from the bed.

Neither RN 1 nor and NA 1 wore a gown and NA 1 did not wear gloves to perform the transfer with Resident 2. At the time of the observation, RN 1 confirmed that the Resident 2 had an open wound on his right leg.

There was an EBP sign posted on his door.

Clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses that included hypothyroidism (an overactive thyroid gland), dementia, and pain.

Review of the clinical record revealed that Resident 11 had a pressure ulcer on the left heel and was identified on the care plan as at risk for MDRO colonization/infection due to the left heel wound.

Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 11 had one unhealed pressure ulcer. On March 25, 2026, at 8:33 a.m., a sign was observed on Resident 11's door indicating EBPs were required for care.

At that time, RN 2, entered the resident's room and proceeded to assist the resident with dressing. RN 2 did not wear a gown to perform care. On March 26, 2026, at 1:30 p.m., the Director of Nursing confirmed that the above identified staff did not follow the facility infection control policy. 28 Pa.

Code 211.10(d) Resident care policies. 28 Pa.

Code 211.12(d)(1)(5) Nursing services.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PENNSBURG, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PENNSBURG MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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